UK   ■-'^'- 


301 


UNIVERSITY  OF  CALIFORNIA 

COLLEGE  OF  DENTISTRY 


EXTENSION  LECTURES 
UC-NRLF 


*B    175    Tfi? 


THE  DISEASES  AND  TREATMENT  OF  THE 
INVESTING  TISSUES  OF  THE  TEETH 


BY 
ARTuriP    D.  BLACK,  A.M.,  M.D.;  D.D.S. 

Pr..f-;<nr    .f  (^n,■,  (ry  and  Special  Demal  Pathology,  N'^''t^"'-^'"'-n  University 

Dental  ''chcol,  Chicago. 


DECEMBER  27,   1915  — JANUARY  7,   1916 


Digitized  by  the  Internet  Arciiive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/diseasestreatmenOOblacrich 


UNIVERSITY  OF  CALIFORNIA 

COLLEGE  OF  DENTISTRY 


EXTENSION  LECTURES 

3 


THE  DISEASES  AND  TREATMENT  OF  THE 
INVESTING  TISSUES  OF  THE  TEETH 


BY 
ARTHUR    D.  BLACK,  A.M.,  M.D.,  D.D.S. 

Professor  of  Operative  Dentistry  and  Special  Dental  Pathology,  Northwestern  University 
Dental  School,  Chicago. 


DECEMBER  27,   1915  — JANUARY  7,   1916 


UNIVERSITY  OF  CALIFORNIA  PRESS 

BERKELEY 

1916 


t? ' 


INTROD^JOTIO^'* 

Before  taking  up  the  work  for  which  we  are  assembled,  I  wish  to 
express  my  appreciation  of  the  honor  conferred  by  the  University  of 
California  in  extending  to  me  an  invitation  to  be  one  of  the  lecturers 
of  this  Institute.  I  am  pleased  also  to  say  a  few  words  in  commenda- 
tion of  the  action  of  the  University  of  California  in  adding  dental 
courses  to  its  extension  work.  It  is  a  compliment  to  the  profession 
that  the  importance  of  our  service  to  humanity  is  thus  recognized,  and 
I  trust  that  these  courses  will  in  future  years  continue  to  receive  the 
hearty  support  of  the  profession.  I  wish,  before  this  class,  to  compliment 
Dean  Millberry  for  having  seen  the  need  of  courses  under  University 
control,  by  men  without  the  sphere  of  influence  of  commercial  interests, 
and  for  having  suggested  the  plan  to  the  University  authorities.  Such 
courses  should  stimulate  the  members  of  the  profession  to  keep  closely 
abreast  of  the  times  and  improve  the  general  average  of  dental  service. 
Thus  we  see  that  the  University  of  California  is  promoting  a  scheme 
in  which  the  people  of  the  entire  State  should  be  interested,  for  they 
will  in  the  end  be  the  beneficiaries. 

The  treatment  of  disease  improves  with  more  complete  knowledge  of 
pathology.  For  each  disease,  we  should  be  able  to  apply  treatment 
closer  to  the  source,  more  directly  to  the  cause,  or  actually  to  prevent  it, 
as  our  understanding  of  the  pathology  becomes  more  perfect.  We  are 
all  familiar  with  the  gradual  advancement  in  the  treatment  of  typhoid 
fever,  especially  in  the  prevention  of  it  by  improved  sanitation  when 
the  methods  of  transmission  became  known,  and  by  vaccination  after 
the  effect  of  the  infection  in  the  development  of  antibodies  was  under- 
stood. The  discovery  of  the  role  which  the  mosquito  played  in  the 
transmission  of  yellow  fever  and  malaria  made  it  possible  for  our  govern- 
ment to  carry  to  completion  the  construction  of  the  Panama  Canal,  the 
failure  of  the  French  attempt  having  been  due  principally  to  the  ravages 
of  these  diseases. 

A  careful  review  of  the  literature  of  dentistry  reveals  little  other 
than  very  meager  statements  of  the  pathology  of  the  diseases  of  the 
peridental  membrane.  The  very  large  majority  of  writings  on  this 
subject  concern  themselves  with  names  applied  by  various  authors, 
with  theories  as  to  local  and  systemic  causes,  and  with  statements 
emphasizing  the  necessity  of  removing  deposits  from  roots  of  the 
teeth.     Very   few   men    seem    to    have   made   »  serious    effort    to   study 


*  This  course  of  lectures  follows  closely  the  recently  published  book 
Special  Denial  Pathology,  by  the  late  Dr.  G.  V.  Black  (Medico-Dental  Pub- 
lishing Co.,  Chicago;  Claudius  Ash,  Sons  and  Co.,  London,  1915),  credit  to 
which  is  hereby  acknowledged.  The  illustrations  herein  were  reproduced  from 
the  same  book,  as  were  about  one  hundred  and  fifty  stereopticon  slides  used 
to  illustrate  the  lectures.  Ol  Q  Q 1^  P  f¥ 


and  pres*ent  "in  fletaii,  'the  pathological  changes  which  take  place  or  to 
differentiate  the  various  diseases"  to  which  the  investing  tissues  are 
subject.  It  is  not  surprising,  therefore,  that  the  many  plans  of  treat- 
ment have  generally  been  unsuccessful.  As  a  basis  for  the  institution 
of  more  rational  treatment,  this  course  of  lectures  will  be  devoted 
largely  to  studies  of  the  histology,  physical  functions  and  pathological 
changes  in  these  tissues.  After  a  time  we  will  come  to  realize  that  many 
of  us  have  been  endeavoring  to  accomplish  the  impossible. 

The  peridental  membrane  is  defined  as  the  soft  tissue  which  serves 
to  connect  the  root  of  the  tooth  with  the  bone  of  the  alveolar  process. 
We  might  refer  to  it  as  the  connecting  link  between  chronic  infection 
of  the  mouth  and  the  general  health,  since  there  is  practically  always 
a  break  in  this  tissue  which  permits  the  infective  agent  to  enter  the 
circulation  and  be  carried  to  distant  parts.  We  might  also  think  of  this 
tissue  as  that  which  must  bind  together  the  medical  and  dental  profes- 
sions in  their  fight  against  the  ever-increasing  list  of  diseases  which 
are  recognized  as  occurring  secondary  to  focal  infections.  We  are  con- 
cerned chiefly  with  the  dentist's  part  in  protecting  the  health  of  his 
patients,  but  we  will  not  overlook  his  duty  to  conserve  the  teeth. 

Disease  of  the  peridental  membrane  does  not  occur  except  as  a 
result  of  (1)  a  preceding  gingivitis  or  (2)  the  death  of  the  dental  pulp. 
In  the  one  case  there  may  occur  a  detachment  of  the  tissue  from  the 
cementum  beginning  at  the  gingival  line  of  the  tooth,  with  the  formation 
of  a  pus  pocket  alongside  the  root;  in  the  other,  the  detachment  occurs 
about  the  apex  of  the  root  with  the  development  of  a  chronic  alveolar 
abscess.  It  will  be  noted  later  that  the  pathological  changes  in  both 
cases  are  similar  and  that  we  are  confronted  with  the  same  difficulties 
in  protecting  the  general  health  from  the  effects  of  these  foci.  We  will 
come  to  realize  also  that  the  danger  to  health  demands  the  elimination 
of  all  such  foci. 

The  chronicity  of  these  diseases  has  led  to  much  confusion  in  our 
ideas  and  knowledge  of  the  pathology.  It  is  not  unusual  for  cases  to 
run  twenty  or  thirty  years  before  all  of  the  teeth  are  lost,  and  few 
dentists  have  the  opportunity  to  observe  many  cases  from  beginning 
to  end.  It  is  not  strange,  therefore,  that  we  have  failed  to  associate 
the  early  symptoms  with  those  of  the  well-established  lesion.  Especially 
have  we  failed  to  recognize  the  relationship  between  the  apparently 
harmless  gingivitis  and  the  secondary  serious  and  generally  incurable 
pericementitis.  We  must  learn  to  correlate  the  clinical  pictures  presented 
by  many  cases  in  various  stages  of  progress  and,  from  these,  make  a 
composite  which  will  give  us  a  better  understanding  of  the  progressive 
changes  which   occur. 

We  must  differentiate  several  distinct  diseases  of  the  gingivae  and 
peridental  membrane  as  to  their  causation,  pathology,  and  treatment,  and 


in  doing  this  we  must  have  a  new  nomenclature.  Terms  which  have 
been  applied  to  a  group  of  diseases  must  be  dropped  and  others  substituted 
which  designate  each  condition;  for  the  retention  of  the  general  terms 
serves  to  continue  in  our  minds  the  confusion  which  has  prevailed.  In 
order  to  have  a  clear  understanding  of  the  pathology,  we  require  terms 
which  will  separate  definitelj''  the  inflammations  of  the  gingivae  from 
those  of  the  peridental  membrane,  for  it  will  be  pointed  out  that  we  may 
generally  cure  the  one,  and  practically  never  the  other.  Therefore, 
successful  preventive  treatment  of  diseases  of  the  peridental  membrane 
necessitates  a  clear  understanding  of  the  pathology,  a  recognition  of 
the  early  stages,  and  the  institution  of  treatment  while  there  is  oppor- 
tunity to  effect  a  cure. 


FIRST    LECTURE 

HISTOLOGY  AND   PHYSICAL   FUNCTIONS   OF   THE   INVESTING 
TISSUES   OF   THE   TEETH 

The  gums,  gingivae,  cementum,  peridental  membrane,  and  the  bone 
of  the  alveolar  process  may  all  be  considered  as  the  investing  tissues 
of  the  teeth.  It  is  important  that  we  have  a  clear  understanding  of  the 
histological  structure  and  physical  functions  of  these  tissues,  in  order 
that  we  may  appreciate  the  significance  of  the  pathological  changes 
which  occur.  This  will,  in  turn,  lead  to  more  rational  treatment.  It  is 
especially  desirable  that  we  realize  the  interdependence  of  these  struc- 
tures upon  each  other  in  the  performance  of  their  normal  functions. 

Gums  and  Gingivae 
The  gums  and  gingivae  are  made  up  of  a  pavement  epithelium  sup- 
ported by  a  base  of  connective  tissue.  The  epithelium  of  the  gingivae 
is  more  dense  than  that  of  the  gums,  the  cells  being  very  flat  and  closely 
packed  together  on  the  surface.  They  are  well  supported  by  many  long 
legs  of  connective  tissues,  each  of  which  carries  one  or  more  blood 
vessels  far  into  the  epithelial  covering.  Provision  is  thus  made  for  the 
rapid  regeneration  of  the  superficial  cells,  which  are  frequently  injured 
or  worn  away  as  a  result  of  the  wear  and  tear  to  which  they  are  sub- 
jected in  mastication.  This  arrangement  also  insures  prompt  healing 
of  injuries  to  the  gingivae  and  enables  this  tissue  to  withstand  long- 
continued  or  often  repeated  irritation  without  serious  harm.  The  gum 
tissue  is  a  rather  insensitive  tissue,  offering  little  complaint  to  injuries 
which  would  excite  much  pain  in  other  tissues.  Occasionally,  however, 
long-continued  irritation,  as  the  rubbing  of  the  edge  of  a  denture,  will 
develop  extreme  hypersensitiveness. 


.  i 


It  will  be  noted  from  the  above  that  one  of  the  important  functions 
of  the  gingivae  is  that  of  protecting  the  underlying  peridental  membrane 
and  alveolar  process.  In  fact,  this  seems  to  be  the  principal  function  of 
the  gingivae.  In  addition,  they  doubtless  are  of  material  service  in 
maintaining  the  teeth  in  the  line  of  the  arch. 

It  is  important  that  we  be  familiar  with  the  nomenclature  of  the 
gingivae  and  peridental  membrane.  We  may  apply  the  term  gingivae 
to  all  the  soft  tissue  which  rests  upon  and  extends  crownwise  from  the 


.■.',.,;Jl^ 


Fig.  1.  Longitudinal  section  through  the  gingiva  and  the  gingival 
portion  of  the  peridental  membrane,  (E)  Epithelium.  (D)  Dentin.  (C) 
Cementum.  (S)  Subgingival  space.  (F)  Free  gingivae  group  of  fibres. 
(A)  Alveolar  crest  group  of  fibres.  (H)  Horizontal  group  of  fibres.  (B) 
Bone  of  alveolar  process. — Noyes. 

crest  of  the  alveolar  process.  This  may  be  subdivided  into  the  body, 
which,  encircling  each  tooth,  extends  from  the  crest  of  the  alveolar 
process  to  the  level  of  the  gingival  line  of  the  tooth,  the  gingival  line 
being  the  line  of  junction  of  cementum  and  enamel.  The  free  gingivae 
are  those  portions  which  overlie  the  enamel  on  the  buccal,  labial  and 
lingual  surfaces  of  the  teeth,  and  the  septal  gingivae  are  the  similar 
portions  which  occupy  the  septal  or  interproximal  spaces.  We  will  have 
occasion  to  refer  frequently  to  the  subgingival  spaces— those  spaces  be- 
tween the  free  gingivae  and  the  enamel,  or  between  the  septal  gingivae 


IT. 


and  the  enamel.  Under  normal  conditions,  a  thin,  flat  blade  may  be 
passed  into  the  subgingival  space,  between  the  free  gingivae  and  the 
enamel,  until  it  comes  in  contact  with  the  attachment  of  the  peridental 
membrane  to  the  cementum  at  the  gingival  line  of  the  tooth. 

The  gingivae  and  peridental  membrane  contain  several  groups  of 
principal  fibres  which  may  be  named  and  briefly  described  in  order, 
beginning  at  the  gingival  line  and  progressing  toward  the  apex  of  the 
root  as  follows: 

The  free  gingivae  group  is  composed  of  those  fibres  which  extend  out- 
ward  from   the  cementum   jnst  beyond  the  gingival  line  and  then  turn 


Fig.  2.     A  portion  of  the  ^    i    ;.     i  .me   i.ctween  two  incisors 

of  a  young  sheep,  showing  the  trans-septal  fibres  extending  from  tooth 
to  tooth. — Noyes. 


occlusally  into  the  free  gingivae.  These  fibres  help  to  support  the  free 
gingivae  and  assist  in  maintaining  their  close  adaptation  to  the  teeth. 
The  trans-septal  group  consists  of  a  strong  band  of  fibres  passing  from 
tooth  to  tooth  through  the  body  of  the  septal  gingivae,  occlusally  of  the 
crest  of  the  interproximal  portion  of  the  alveolar  process.  The  principal 
function  of  this  group  of  fibres  is  to  maintain  the  contacts  between  the 
various  teeth — to  keep  the  contacts  tight.  It  is  necessary  to  appreciate 
the  function  of  these  fibres  in  order  to  understand  the  movements  of 
of  the  teeth  and  the  progressive  involvement  of  several  proximal  surfaces 
from  an  original  pus  pocket  on  a  proximal  surface.  This  will  be  fully 
explained  later. 


A« 


8 

The  alveolar  crest  group  consists  of  those  fibres  which  extend  outward 
from  the  cementum  and  are  attached  to  the  crest  of  the  alveolar  process. 
Their  principal  function  seems  to  be  to  steady  the  tooth  against  lateral 
strain. 

The  horizontal  group  consists  of  those  fibres  which  extend  outward 
at  right  angles  to  the  long  axis  of  the  tooth  and  are  attached  to  the  bone 
of  the  alveolar  process,  just  below  its  crest.  These  fibres  act  with  those 
of  the  alveolar  crest  group  in  preventing  too  much  lateral  movement  of 
the   teeth. 

The  oblique  group  consists  of  the  fibres  which  make  up  the  bulk  of  the 
peridental  membrane.  They  are  attached  to  the  greater  part  of  the  sur- 
face of  the  root,  and  extend  in  an  oblique  direction  occlusally  to  the 
bone  of  the  alveolar  process,  serving  to  swing  the  tooth  in  its  socket  and 
support  it  against  the  stress  of  mastication. 

The  apical  fan-shaped  group  consists  of  the  many  bundles  of  fibres 
attached  about  the  apex  of  the  root  which  radiate  in  all  directions  and 
are  attached  to  the  surrounding  bone.  These  fibres  tend  to  maintain 
the  apex  of  the  root  in  its  central  position  in  the  socket. 

Cementum 

The  cementum  is  one  of  the  most  important  tissues  to  be  considered, 
for  its  peculiar  structure  is  in  large  measure  responsible  for  the  chron- 
icity  of  diseases  of  the  peridental  membrane.  The  cementum  is  contin- 
uous growing,  being  gradually  built  by  the  cementoblasts  which  lie  upon 
its  surface.  These  cells  are  to  be  considered  as  an  integral  part  of  the 
peridental  membrane,  as  they  occupy  the  space  between  the  fibres  and, 
by  their  action,  build  cementum  around  the  fibres,  thus  attaching  them 
to  the  root. 

Cementum  is  closely  analagous  to  the  subperiosteal  bone.  It  is  built 
by  cementoblasts  lying  on  its  surface,  as  is  subperiosteal  bone  by  the 
osteoblasts  on  its  surface.  The  most  important  difference  is  that  bone 
has  a  circulation  of  blood  within  and  throughout  its  structure,  while 
cementum  has  not.  This  is  a  very  important  fact  to  remember.  When 
there  is  a  suppurative  detachment  of  the  periosteum  from  bone,  the 
underlying  bone  dies.  Then,  as  a  result  of  the  circulation  within  the 
bone,  a  line  of  demarkation  is  established  and  the  dead  bone  is  ex- 
foliated. When  the  peridental  membrane  is  detached  from  the  cementum 
by  suppuration,  the  death  of  the  cementum  occurs  in  the  same  manner, 
but  owing  to  the  lack  of  circulation  within  the  cementum,  the  dead 
portion  cannot  be  thrown  off,  but  remains  as  a  constant  irritant  to  the 
overlying  tissue.  This  is  the  principal  factor  in  maintaining  the  chron- 
icity  of  the  pus  pocket  alongside  the  root  and  the  chronic  alveolar 
abscess. 


§A 


Peridental  Membrane 

The  peridental  membrane  contains  many  specialized  elements.  The 
various  groups  of  principal  fibres  have  already  been  mentioned,  as  have 
the  cementoblasts  and  osteoblasts.  There  are  also  many  strings  of  epi- 
thelial cells  which  form  a  more  or  less  definite  network  about  the  root 
of  the  tooth.  The  function  of  these  cells  has  not  been  definitely  deter- 
mined. Some  investigators  think  they  are  the  remains  of  those  cells 
which  formed  the  enamel  organ  and  are  liable  to  break  down  easily  as 
a  result  of  certain  toxins  in  the  circulation.  Others  contend  that  they 
have  been  so  placed  for  the  especial  purpose  of  combating  infections 
of  the  peridental  membrane — that  they  multiply  rapidly  and  accomplish 
the  encystment  and  destruction  of  the  infective  agents  and  their  products. 
We  are  inclined  to  the  latter  view. 

The  blood-supply  of  the  peridental  membrane  is  unusually  good. 
Vessels  enter  about  the  apex  of  the  tooth  and  pass  alongside  the  root, 
other  vessels  enter  over  the  crest  of  the  bony  alveolus,  and  still  others 
pass  directly  through  the  bone.  With  this  triple  source  of  supply  the 
practice  of  removing  the  pulps  of  teeth  with  the  thought  of  diverting 
an  increase  of  blood  to  the  peridental  membrane  would  seem  to  be  an 
unwarranted  procedure. 

Alveolar  Process 

The  alveolar  process  is  true  bone.  However,  it  should  be  considered  an 
appendage  of  the  tooth.  It  is  built  about  the  tooth  as  the  tooth  grows; 
it  disappears  following  the  extraction  of  the  tooth.  It  seems  logical  to 
state  that  the  physiological  process  of  absorption,  by  which  the  peridental 
membrane  and  alveolar  process  are  removed  following  the  extraction  of 
a  tooth,  also  plays  a  considerable  part  in  the  changes  which  take  place 
following  suppurative  detachments  of  the  peridental  membrane  from  the 
cementum.  We  should  expect  the  detached  fibres,  as  well  as  the  bone 
to  which  their  outer  ends  are  attached,  to  be  absorbed,  even  though 
they  were  not  involved  in  the  suppuration. 

It  seems,  therefore,  that  there  is  a  physiological  interdependence  of 
the  various  investing  tissues  which  requires  that  the  health  of  all  be 
maintained;  that  serious  injury  to  one  is  likely  to  impair  them  all;  and 
that  the  gingivae  stand  guard  to  protect  these  underlying  tissues.  As  we 
study  the  diseases  of  these  tissues  we  will  come  to  appreciate  more  and 
more  the  importance  of  preserving  the  gingivae  in  good  health  in  order  to 
prevent  disease  of  the  peridental  membrane. 


L^ 


10 


SECOND  LECTURE 

STUDIES  OF  SALIVARY  CALCULUS 

INFLAMMATIONS  CAUSED  BY  SALIVARY  CALCULUS 

AND  TREATMENT 

In  view  of  the  fact  that  the  injuries  due  to  deposits  of  salivary 
calculus  have  been  recognized  since  the  earliest  historical  times,  it  seems 
strange  that  so  little  effort  has  been  made  to  study  the  causes  and  nature 
of  the  deposit.  Credit  is  due  Dr.  Henry  H.  Buchard  for  having  made 
the  first  serious  effort  in  this  direction.*  Dr.  Buchard 's  theory  was 
based  on  the  fact  that  water  containing  carbon  dioxide  will  dissolve  a 
greater  quantity  of  various  salts  than  it  will  without  the  gas,  and  its 
ability  of  dissolving  these  salts  is  further  increased  by  the  addition  of 
more  of  the  gas  under  pressure.  If  water  is  charged  with  carbon  dioxid 
under  pressure  in  a  closed  tank,  its  power  of  dissolving  the  salts  will  be 
increased  in  proportion  to  the  quantity  of  the  gas.  Then,  if  the  pressure 
is  released,  the  excess  of  gas  will  be  given  off  and  the  corresponding 
excess  of  salts  held  in  solution  will  be  precipitated.  In  the  human  body, 
the  fluids  are  charged  with  carbon  dioxid  under  the  blood  pressure,  and 
are  therefore  capable  of  holding  excessive  amounts  of  calcium  and  other 
salts  in  solution.  When  the  fluids  are  discharged  (as  the  flowing  of 
the  saliva  from  Stenson's  duct),  they  are  released  from  the  blood 
pressure,  and  the  excess  of  carbon  dioxid  escapes,  while  a  due  propor- 
tion of  salts  is  precipitated.  It  was  reasoned  that  in  the  mouth  this 
precipitate  would  be  caught  in  a  curd  formed  by  the  action  of  lactic 
acid  on  the  mucus,  the  lactic  acid  being  formed  by  micro-organisms 
normal  to  the  mouth,  and  the  precipitated  salts  and  the  curd  would 
settle  down  in  out-of-the  way  places  and  by  additions  would  finally  form 
a  hard  mass  of  calculus. 

It  was  not  easy  to  prove  this  theory.  Dr.  Burchard,  in  his  experi- 
ments, found  that  saliva  collected  in  a  test-tube,  and  allowed  to  stand, 
would  be  cloudy  within  twenty-four  hours  and  it  was  thought  that  this 
cloud  was  the  precipitate  of  calcium  salts. 

This  was  the  generally  accepted  theory  until  Dr.  G.  V.  Black  under- 
took his  long  series  of  experiments  about  seven  years  ago.  He  first 
duplicated  Dr  Burchard 's  experiments  with  the  same  results.  It  then 
occurred  to  him  that  it  was  not  proven  that  the  cloud  in  the  test-tube 


Dental  Cosmos,  vol.  37,  1895,  p.  821. 


11 

was  calcium  salts.  He  contrived  to  centrifuge  the  contents  of  the  tube, 
collecting  it  on  a  microscopic  cover-glass  held  in  the  bottom  of  the  tube, 
and  found  that  the  cloud  was  composed  entirely  of  a  growth  of  micro- 
organisms. 

Many  new  lines  of  investigations  were  then  taken  up.  Our  time 
is  too  limited  to  do  more  than  recite  certain  of  the  more  important 
findings.  Systematic  examinations  were  made  of  artificial  dentures 
and  it  was  noted  that  the  mucus,  which  gives  a  denture  a  greasy  feeling, 
could  be  readily  washed  off  with  the  water  running  from  the  hydrant, 
but  that  there  would  frequently  remain  a  new  soft  deposit  of  calculus. 
It  was  observed  that  this  could  be  easily  removed  with  a  brush  and  plain 
water  if  this  was  done  before  the  deposit  had  remained  as  long  as  fifteen 
or  twenty  hours,  but  that  it  was  difficult  or  sometimes  impossible  to 
remove  the  deposit  with  the  brush  if  it  remained  twenty-four  hours. 
This,  of  itself,  offers  a  most  practical  suggestion  for  the  prevention  of 
the  accumulation  of  these  deposits  on  the  teeth  by  thorough  brushing 
twice  daily. 

An  upper  denture  was  then  constructed  with  a  little  rectangular  gold 
frame  attached  to  the  vulcanite  above  the  buccal  surfaces  of  the  molars. 
This  frame  was  held  in  place  by  two  screws  and  was  so  arranged  that 
a  specially  ground  cover-glass  was  held  under  the  frame  and  could  be 
removed  and  carried  to  the  microscope  for  examination  without  disturbing 
whatever  might  be  collected  upon  it.  It  was  thus  possible  to  secure  and 
examine  deposits  in  all  stages,  from  the  very  fresh  soft  deposits  to  those 
which  were  quite  hard.  Various  staining  methods  were  employed  to  bring 
out  more  clearly  the  structural  characteristics.  It  was  also  possible  to 
make  photomicrographs  of  all  specimens. 

This  line  of  investigation  developed  several  important  facts.  It  was 
quickly  recognized  that  the  deposit  was  not  a  precipitate,  as  had  been 
supposed,  but  that  the  forms  were  all  spherical,  and  the  material  con- 
stituting the  deposit  was  a  calco-globulin,  and  this  globulin  brings  with 
it  the  calcium  elements  which  eventually,  with  the  decomposition  of  the 
globulin,  form  the  hard  deposits.  This  globulin  is  called  the  agglutinin 
of  salivary  calculus.  Eepeated  examinations  showed  the  primary  deposit 
to  consist  of  minute  spherules  (smaller  than  red  blood  corpucles)  which 
gradually  coalesced  to  form  larger  massses  of  more  or  less  rounded 
forms. 

It  was  also  determined  that  the  outpouring  of  the  deposit  is  decidedly 
paroxysmal;  this  is  one  of  the  striking  characteristics.  It  was  later  dis- 
covered that  the  paroxysms  are  of  comparatively  short  duration  and 
occur  within  a  few  hours  after  a  heavy  meal.  If,  for  example,  a  heavy 
meal  were  eaten  at  noon,  the  cover-glass  on  the  denture  would  remain 
clear  until  possibly  two  o'clock,  when   the  paroxysm  of  deposit   would 


12 

begin.  It  would  continue  for  an  hour  and  a  half  or  two  hours  and  then 
cease.     A  new  glass  placed  at  this  time  would  remain  clear. 

These  experiments  seem  to  have  established  the  fact  that  a  heavy 
meal,  especially  when  well  digested,  puts  into  the  system  more  of  nutrient 
material  than  is  required,  and  that  a  i)roper  balance  is  restored  by  the 
paroxysmal  outpouring  of  the  calco-globulin  with  all  the  secretions  and 
excretions,  each  of  the  body  juices  and  fluids  having  its  due  proportion. 
Persons  subject  to  frequent  heavy  deposits  were  able  to  continue  for 
weeks  without  any  deposits  when  they  reduced  the  amount  of  food  taken 
a  little  below  that  to  which  they  were  accustomed.  During  such  a  period, 
a  single  heavy  meal  would  result  in  a  paroxysm  of  deposit.  It  seems  to 
make  no  difference  what  foods  are  selected  for  the  heavy  meal. 

Many  other  experiments  were  performed  which  can  not  be  enumerated 
in  this  course.  One  other  thing  should  be  mentioned — a  special  grinding 
machine  was  constructed  and  a  technie  developed  by  which  very  thin  sec- 
tions of  the  hard  salivary  and  serumal  deposits  could  be  ground  thin 
enough  to  be  available  for  microscopic  study  and  photographing.  These 
showed  the  structure  of  the  hard  deposits  to  be  similar  to  the  soft  deposits 
caught  on  the  cover-glasses. 

INFLAMMATIONS  DUE  TO  DEPOSITS  OF   SALIVAEY   CALCULUS 

Deposits  of  calculus  always  occur  on  hard  substances.  In  the  mouth 
we  find  these  deposits  on  the  teeth,  and  on  crowns,  bridges,  artificial 
dentures,  and  other  appliances.  The  position  of  the  deposit  is  most  likely 
to  be  near  the  orifices  of  the  ducts  from  the  salivary  glands;  upon  the 
buccal  surfaces  of  the  molars  and  the  lingual  surfaces  of  the  lower 
incisors.  The  initial  deposit  is  usually  at  the  position  of  the  crest  of  the 
free  gingivae  and  occurs  because  there  has  been  a  slight  blunting  of  the 
normally  thin  edge.  Such  a  blunting,  or  some  irregularity  of  form,  seems 
necessary  for  the  initial  deposits  to  become  attached.  This  fact  should 
emphasize  the  importance  of  keeping  the  gingivae  in  good  health  with 
normal  thin  crests. 

Gingivitis  Caused  by  Deposits  oi'  Salivary  Caiculus 
When  the  initial  deposit  in  any  position  has  become  hard,  there  is  an 
irritation  of  the  underlying  gingivae.  This  form  of  gingivitis,  with  the 
gradual  accumulation  of  the  deposit,  is  distinct  from  others.  There  are 
frequent  suppurations  of  the  shelf  of  gingivae  which  is  in  contact  with 
the  deposit.  As  the  deposit  increases,  it  gradually  destroys  the  gingivae 
and  is  apt  to  replace  in  contour  the  lost  tissue.  The  most  striking 
feature  of  this,  in  comparison  with  certain  other  forms  of  gingivitis,  is 
that  there  is  little  tendency  for  the  inflammation  to  involve  any  other 
tissue  than  that  of  the  shelf  which  is  in  contact  with  the  deposit. 


13 


Pericementis  Caused  by  Deposits  of  Salivary  Calculus 

If  the  deposit  is  not  removed,  it  is  likely  to  destroy  all  the  gingivae 
and  encroach  upon  the  peridental  membrane,  gradually  destroying  not 
only  the  peridental  membrane,  but  also  the  bone  of  the  alveolar  process 
and  overlying  gum  tissue.  In  all  of  this  there  is  the  tendency  for  the 
attachment  of  fibres  of  the  peridental  membrane  to  be  maintained  to 
the  level  of  the  tissue  destroyed  by  the  deposit.  There  is  little  tendency 
to  the  stripping  off  of  the  peridental  membrane  from  the  cementum  and 
the  formation  of  pus  pockets  alongside  the  roots.     Deposits  of  salivary 


Fig.  3 


Fig.  4 


Fig.  3.  Drawing  illustrating  a  slight  deposit  on  the  lingual  surface 
of  a  lower  incisor  which  has  caused  a  gingivitis  only,  not  having  pro- 
gressed far  enough  to  involve  the  attachment  of  the  peridental  membrane 
to  the  cementum. 

Fig,  4.  Drawing  illustrating  a  still  greater  destruction,  including 
also  the  labial  tissues. 


calculus  should  not  therefore  be  considered  a   cause  of  pus  pocket  for- 
mation, as  has  commonly  been  thought. 

As  the  destruction  of  the  investing  tissues  continues,  the  patient 
may  complain  of  occasional  pain  and  soreness  and  the  teeth  may  gradually 
become  loose,  so  that  eventually  they  are  lost.  This  is  a  slow  process, 
usually  extending  over  many  years,  and  as  suppurations  are  frequent, 
the  menace  to  the  health  is  probably  greater  than  has  been  realized.  The 
thin-walled  blood  vessels  in  the  granulating  surfaces  offer  micro-organisms 
easy  access  to  the  blood  stream. 


^k 


14 


Treatment 


The  treatment  of  the  inflammations  caused  by  deposits  of  salivary 
calculus  should  always  be  undertaken  with  the  possibilities  of  preven- 
tion well  in  mind.  It  has  been  stated  that  fresh  deposits  are  so  soft 
for  fifteen  or  twenty  hours  that  they  may  be  easily  removed  with  a  brush 
and  plain  water.  Therefore,  every  patient  who  may  be  induced  to  brush 
the  teeth  thoroughly  twice  every  day  can  jjrevent  the  inflammation  and 
destruction  caused  by  the  hard  deposit.  This  has  been  sufliciently  well 
demonstrated  in  many  cases  to  leave  no  room  for  doubt  of  its  efficacy. 

Our  management  of  cases  presenting  with  deposits  should  be  with  the 
view  of  gaining  the  co-operation  of  the  patient  to  the  end  that  future 
deposits  will  be  prevented.  The  removal  of  the  deposits  is  not  difl&cult. 
They  are  practically  always  in  sight;  not  covered  by  the  gingivae.  Only 
a  few  simple  instruments  are  required.  After  the  removal  of  the  deposits, 
the  surfaces  of  the  teeth  should  be  polished.  If  there  is  much  inflamma- 
tion, frequent  rinsing  of  the  mouth  with  warm  salt  solution  will  keep 
the  field  clear  and  lessen  the  patient's  discomfort. 

In  such  cases  it  is  usually  best  not  to  advise  the  patient  as  to  the 
technic  of  proper  mouth  hygiene  at  the  time  when  the  deposits  are 
removed.  This  should  be  reserved  until  the  inflammation  has  subsided. 
The  patient  should  be  given  another  appointment  and  should  then  receive 
whatever  instruction  seems  necessary  to  gain  his  interest  and  co-operation. 
This  should  include  a  few  brief  statements  explaining  the  nature  of  the 
fresh  deposit  and  the  possibility  of  preventing  its  accumulation  by 
faithful  brushing  twice  daily.  It  should  also  include  mention  of  the 
danger  to  the  general  health,  as  well  as  the  probable  eventual  loss  of 
the  teeth.  Brushes  should  be  selected,  their  movements  demonstrated 
and  instructions  given  to  the  finest  detail. 

If  posssible,  a  definite  arrangement  should  be  made  for  a  subsequent 
examination,  so  that  we  may  know  how  well  the  home  care  is  progressing. 
A  chart  of  the  mouth,  showing  locations  of  deposits,  should  have  been  made 
at  the  time  of  examination  and  each  position  should  be  carefully  inspected, 
deposits  removed  if  there  are  any,  and  additional  instruction  given  the 
patient.  Considerable  diplomacy  is  necessary  in  the  management  of  many 
patients,  but  one  who  comes  to  realize  fully  the  effectiveness  of  this 
plan  is  sure  to  become  more  and  more  enthusiastic  and  more  successful  in 
gaining  and  holding  the  interest  and  co-operation  of  the  patients. 


A-%. 


15 


THIRD  LECTURE 

GINGIVITIS   CAUSED   BY   DEPOSITS   OF   SERUMAL   CALCULUS 
WITH  TREATMENT 

In  considering  the  inflammations  of  the  gingivae  caused  by  deposits 
of  serumal  calculus,  we  have  to  do  only  with  the  deposits  which  occur  on 
the  enamel  of  the  subgingival  spaces.  A  serum  is  normally  poured  out 
into  these  spaces  to  keep  them  moist.  We  should  expect  this  serum  to 
contain  its  proportionate  share  of  calco-globulin,  whenever  there  is  a 
paroxysm.     As  the  quantity  of  serum  is  small  compared  with  the  amount 


mmm^^ 


Fig.  5. 


Fig.  6. 


Fig.  5.  Drawing  illustrating  a  deposit  of  serumal  calculus  under  the 
free  gingiva  on  the  labial  surface  of  the  enamel  of  a  lower  incisor  tooth. 

Fig.  6.  Drawing  illustrating  a  similar  deposit  on  the  lingual  surface 
of  an  upper  incisor.  Suppuration  of  the  peridental  membrane,  resulting 
from  deposits  in  this  position,  causes  the  teeth  to  move  labially,  and  such 
cases  are  generally  hopeless,  after  much  progress  has  been  made. 

of  the  saliva,  so  will  the  deposits  be  small  and  slow  of  formation.  The 
causes  are  the  same,  and  the  nature  of  the  deposit  is  the  same  as  salivary 
calculus.  We  will  often  find  both  deposits  in  the  same  mouth.  However, 
proper  care  or  vigorous  mastication  may  prevent  the  accumulation  of 
salivary  deposits,  while  serumal  deposits  are  being  laid  down. 

Owing  to  the  fact  that  the  gingivae  naturally  hug  closely  about  the 
teeth,  the  deposits  occurring  in  the  subgingival  spaces  are  likely  to  be 


16 

compressed  while  soft,  and  harden  as  flattened  scales.  If  the  close  adapta- 
tion of  the  gingivae  is  lost  as  a  result  of  inflammation  or  detachment  of 
the  peridental  membrane,  the  form  of  the  deposit  will  generally  be 
nodular  instead  of  flat. 

Clinically,  these  deposits  may  be  divided  into  two  groups:  one  in 
which  there  is  a  general  deposit  in  the  subgingival  spaces  in  the  form 
of  narrow  bands  more  or  less  completely  encircling  the  teeth.  The  inflam- 
mation of  the  overlying  gingivae  may  or  may  not  be  apparent.  In  such 
mouths  deposits  of  salivary  calculus  are  usually  present.  In  the  other 
group,  the  deposits  will  be  confined  to  certain  teeth,  others  being  free. 
In  such  cases  an  inflammation  of  the  gingivae  about  the  particular  teeth 
has  usually  preceded  the  occurrence  of  the  deposit.  An  irritation,  such 
as  the  wedging  of  food  through  an  open  contact,  or  an  ill-fitting  crown, 
causes  the  outpouring  of  greatly  increased  amounts  of  serum  from  the 
inflamed  gingivae,  thus  delivering  to  these  spaces  a  correspondingly 
increased  amount  of  calco-globulin  for  deposit.  We  therefore  find  con- 
siderable deposits  in  such  locations,  with  little  or  none  elsewhere  in  the 
mouth.  It  is  not  uncommon  to  find  deposits  on  the  lingual  surfaces  of  the 
upper  incisors,  from  the  irritation  caused  by  food  forced  against  the 
gingivae  by  the  lower  incisors,  especially  if  there  is  much  overbite. 

In  all  cases  in  which  there  are  deposits  of  serumal  calculus  in  the 
subgingival  spaces,  these  cause  inflammation  of  the  overlying  gingivae, 
and  occasionally  suppuration  occurs.  The  tissues  may  recover  without 
serious  harm  having  been  done.  Sooner  or  later,  however,  a  suppuration 
will  involve  the  attachment  of  the  peridental  membrane  at  the  gingival 
line  and  a  little  pus  pocket  will  be  formed.  In  this  way  these  deposits 
become  the  real  exciting  cause  of  suppurative  detachments  of  the  peri- 
dental membrane  in  probably  twenty  per  cent  of  cases. 

Treatment 

The  treatment  of  inflammations  caused  by  these  deposits  should  be 
along  the  same  general  lines  as  that  mentioned  for  salivary  deposits. 
More  delicate  instruments  are  required,  also  a  higher  degree  of  finger 
skill.  One  must  learn  to  feel  the  deposits  and  to  recognize  a  surface  free 
of  deposit  in  positions  where  he  cannot  see.  While  proper  brushing  by 
the  patient  will  assist  in  keeping  the  gingivae  in  good  health,  the  use 
of  a  rubber  bulb  syringe  to  wash  out  the  subgingival  spaces  thoroughly 
twice  a  day  is  much  more  efficacious.  This  requires  more  careful  training 
and  instruction  and  more  of  enthusiasm  to  get  patients  keyed  up  to  the 
point  at  which  their  interest  and  care  will  be  maintained.  A  similar 
plan  of  recording  positions  of  deposit,  of  subsequent  examinations,  etc., 
should  be  followed.     Even  in  mouths  free  from  these  deposits,  nothing 


17 


Figs.  7,  8,  9.  Three  molar  teeth  showing  "rings"  of  deposits  of  ser- 
umal  calculus  on  the  enamel  of  the  subgingival  space.  Frequently  these 
"rings"  encircle  the  crown.  Specimens  from  i>i^orthwestern  University 
Dental  Museum. 


Fig.  10.  The  position  of  the  rubber  bulb  syringe  in  washing  the 
subgingival  spaces  or  pus  pockets.  The  end  of  the  nozzle  shouJd  touch  the 
enamel  of  the  tooth  near  the  crest  of  the  gingivae  as  it  is  passed  along 
the  arch,  the  angle  being  such  that  the  water  or  solution  will  be  forced 
into  the  subgingival  spaces.  This  is  the  most  effective  means  of  prevent- 
ing deposits  of  serumal  calculus. 


18 


will  contribute  so  greatly  to  the  maintenance  of  the  gingivae  in  good 
health  as  the  twice  daily  irrigation  of  the  subgingival  spaces  with  warm 
water  or  normal  salt  solution. 


GINGIVITIS    CAUSED    BY    INJUEIES,    WITH    TKEATMENT 

In  our  studies  of  the  histology  and  physical  powers  of  the  investing 
tissues,  the  protective  function  of  the  gingivae  was  noted.  The  gingivae 
are  naturally  equipped  to  withstand  severe  punishment,  which  they  do  in 
a  remarkable  way.  The  fact  that  they  will  maintain  themselves  so 
long  under  continued  irritation,  together  with  our  failure  to  recognize 
these  injuries  as   forerunners   of  more   serious   lesions   of   the   peridental 


Figs.  11,  12.  Photographs  of  plaster  models  of  a  case  before  and 
after  contact  restoration.  The  patient  presented  with  a  slight  pocket 
on  the  mesial  surface  of  the  root  of  the  first  molar  on  account  of  the 
open  contact.  The  mesial  surface  of  the  first  molar  and  distal  of  the 
second  bicuspid  were  free  from  decay  and  had  not  been  filled.  The 
separation  had  occurred  as  a  result  of  flat  fillings  in  the  mesial  of  the 
second  bicuspid  and  distal  of  the  first  bicuspid.  These  fillings  were 
removed,  and  a  Perry  separator  was  applied  on  several  occasions  to  move 
the  second  bicuspid  back  into  contact  with  the  first  molar,  it  being  held 
there  for  a  time  with  fillings  of  base-plate  gutta-percha.  Later,  permanent 
fillings  were  made,  restoring  normal  conditions,  as  shown  in  Fig.  12.  It 
was  necessary  to  relieve  the  occlusion  on  the  distal  slopes  of  the  cusps 
of  the  second  bicuspid  as  it  was  moved. 


19 

membrane,  has  led  to  much  abuse  and  neglect.  Yet  it  seems  fair  to 
state,  from  statistics  which  will  be  presented,  that  possibly  seventy-five 
per  cent  of  the  pus  pockets  alongside  roots  of  the  teeth  are  the  direct 
result  of  long-continued  and  neglected  injuries  to  the  gingivae. 

With  an  irritation  of  the  gingivae  from  any  form  of  injury,  there 
is  opportunity  for  suppuration,  with  subsequent  involvement  of  the  attach- 
ment of  the  peridental  membrane.  As  has  been  mentioned,  the  irritation 
is  likely  to  result  in  a  deposit  of  serumal  calculus,  which  becomes  a 
secondary  cause  of  the  further  progress  of  the  case.  In  connection  with 
the  more  acute  suppurations  there  is  often  considerable  pain.  Absorptions 
of  the  gingivae  occur  as  a  result  of  the  constant  irritations*  and  repeated 
suppurations. 

It  would  be  almost  impossible  to  cite  all  the  causes  of  these  injuries. 
Lack  of  contact  of  the  teeth  due  to  extractions  of  neighboring  teeth, 
flat  fillings,  crowns,  etc.,  improjjer  contact  of  teeth,  irregularities  of 
contour  due  to  sharp  edges  of  cavities,  bad  margins  of  fillings  and 
crowns,  etc.,  abuse  of  these  tissues  in  operations,  and  injuries  by  patients 
in  cleaning,  are  the  most  frequent  causes. 

In  cases  in  which  contacts  are  not  normal,  and  food  is  wedged  between 
the  teeth,  the  septal  gingivae  become  inflamed  from  the  repeated  im- 
pactions of  food,  also  from  the  efforts  to  remove  it.  These  impactions 
will,  after  a  time,  result  in  the  absorption  of  the  central  portion  of  the 
septal  tissue,  while  the  buccal  and  lingual  portions  may  be  pushed  out- 
ward in  their  respective  embrasures.  Their  appearance  is  that  of  slightly 
swollen  festoons.  Later  on,  as  the  central  portion  is  further  depressed, 
there  is  likely  to  be  some  absorption  of  the  buccal  and  lingual  portions 
also.  This  may  continue  until  the  absorption  has  included  much  of  the 
bone  of  the  alveolar  septum,  with  deep  pus  pockets  on  the  proximal 
surfaces  of  the  teeth. 

Some  patients  will  complain  bitterly  of  the  pain  caused  by  slight 
impactions  of  food,  others  will  seem  unconscious  of  the  presence  of  con- 
siderable accumulations  in  many  spaces.  Treatment  should  therefore 
be  undertaken  on  the  basis  of  the  impaction  and  inflammation,  rather 
than  on  the  complaint  of  the  patient. 

Several  years  ago,  in  order  to  get  some  reasonably  reliable  data 
as  to  the  frequency  of  the  various  forms  of  gingivitis,  I  requested  a 
number  of  dentists  in  various  sections  of  the  country  to  assist  me  in 
collecting  certain  statistics.  T  sent  a  number  of  examination  cards  to 
each  man  with  a  request  that  he  make  a  careful  record  of  the  areas 
of  gingivitis  found  in  the  mouths  of  young  adults,  who  had  no  disease 
of  the  peridental  membrane.  I  present  herewith  a  brief  summary  of 
the  results  of  the  examination  of  500  mouths  of  persons  between  twenty 
and   thirty-five  years  of  age. 


20 

Of  the  500  mouths  examined,  but  25  were  reported  as  having  no 
gingivitis.  For  the  other  475  persons,  4265  areas  of  gingivitis  were 
reported — an  average  of  8.53  areas  per  person  for  the  entire  500.  Of 
these  areas,  1348  were  due  to  deposits  of  salivary  calculus.  These  were 
in  the  mouths  of  39  per  cent  of  persons  examined,  and  represent  31  per 
cent  of  all  areas  of  gingivitis.  In  recording  these,  each  surface  of  each 
tooth  having  a  deposit  was  counted  as  one  area.  For  example,  a  deposit 
on  the  lingual  surface  of  the  lower  incisors  and  cuspids  was  counted  as  six 
areas. 

Five  hundred  and  sixty-three  areas  were  reported  as  having  deposits 
of  serumal  calculus  on  the  enamel  of  the  subgingival  spaces.  These  were 
in  the  mouths  of  15  per  cent  of  persons  examined,  and  represent  13 
per  cent  of  all  areas  of  gingivitis.  Many  who  had  deposits  of  salivary 
calculus  also  had  serumal  deposits;  140  persons  were  reported  as  having 
either  or  both,  leaving  360  without  deposits  of  either  kind. 

There  were  2364  areas  due  to  other  causes  than  deposits.  Of  these, 
783  were  due  to  bad  margins  of  fillings  or  crowns,  496  to  lack  of  contact 
of  fillings  or  crowns,  305  to  improper  contact  of  fillings  or  crowns,  263 
to  malpositions  or  atypical  forms  of  proximal  surfaces,  255  to  lack  of 
contact  with  no  decay  of  proximal  surfaces,  233  to  caries,  and  19  to  worn 
contacts. 

If  we  add  together  the  number  of  areas  due  to  bad  margins,  lack  of 
contact  or  improper  contact  of  fillings  or  crowns,  the  total  is  1584.  This 
number  of  areas,  37  per  cent  of  all,  may  be  properly  charged  to  imperfect 
dental  operations.  This  is  an  average  of  more  than  three  such  areas  per 
mouth,  and  would  seem  to  indicate  that  fully  one-third  of  the  pus  pockets 
are  due  to  lack  of  care  in  operative  and  prosthetic  service. 

There  was  a  time  when  no  consideration  whatever  was  given  to  the 
soft  tissues  in  the  performance  of  either  filling  or  crowning  operations. 
When  files  were  used  to  separate  the  teeth,  and  wedges  were  driven 
between  them,  the  importance  of  preserving  the  investing  tissues  could 
not  have  been  appreciated.  It  has  only  been  within  comparatively 
recent  years  that  the  attitude  of  the  profession  has  begun  to  change. 
Not  until  we  realize  the  direct  relationship  of  these  areas  of  gingivitis 
to  the  more  serious  detachments  of  the  peridental  membrane  which  follow, 
will  we  be  as  careful  as  we  should  be  in  the  finer  technic  of  all  opera- 
tions so  that  the  number  of  these  injuries  will  be  reduced  to  the 
minimum. 

Treatment 
In  the  treatment  of  cases  of  this  kind,  it  is  essential  that  we  should 
first  make  careful  search  for  the  cause.     When  this  has  been  found,  the 
treatment   will   be   indicated.     If,  because   of   an    open   contact,   food   is 


21 

wedging  between  the  teeth  and  injuring  the  septal  gingivae,  we  must,  if 
possible,  learn  the  cause  of  the  open  contact.  It  may  bo  that  the  cusp 
of  a  tooth  in  the  opposite  arch  needs  a  little  grinding,  or  the  extraction 
of  a  tooth  may  have  permitted  movement  of  others,  opening  the  contacts. 
Many  times  it  is  a  flat  filling  which  did  not  restore  contact,  or  it  may 
be  any  one  of  many  things.  Most  of  these  are  easily  corrected  and  the 
gingivitis  will  promptly  subside  when  the  cause  of  the  irritation  is 
eliminated.  It  is  not  so  much  the  difficulty  of  correcting  these  conditions, 
as  it  is  the  necessity  of  appreciating  the  importance  of  it. 

When  a  contact  is  too  broad,  though  tight,  it  should  be  corrected  by 
trimming  to  proper  form.  Other  things  should  be  done  as  required  in 
particular  cases.  Many  require  careful  study.  Close  attention  to  these 
things  will  impress  the  possibilities  of  prevention  by  greater  care  in 
every  operation  performed. 

In  all  of  the  operations  for  contact  restoration,  one  of  the  most 
important  things  is  proper  separation  of  the  teeth  without  pain  or  injury 
to  the  soft  tissues.  Notwithstanding  all  of  the  more  recent  devices, 
I  know  of  nothing  so  satisfactory  as  the  Perry  separators.  These  seem 
to  meet  every  requirement.  A  little  experience  is  necessary  to  be  able  to 
adjust  them  properly,  and  thA^  are  more  expensive  than  other  devices, 
yet  in  the  long  run  they  are  very  econon)ical,  when  one  considers  the 
time  saved  and  the  benefits  gained  by  their  use. 


FOURTH  LECTURE 

CHEONIC  SUPPURATIVE  PERICEMENTITIS 

The  term  '*  chronic  suppurative  pericementitis"  is  applied  to  that 
disease,  the  essential  characteristic  of  which  is  the  formation  of  a  pus 
pocket  alongside  the  root  of  a  tooth.  This  term  was  selected  because 
it  is  closely  descriptive  of  the  condition.  <")ne  of  the  marked  features  of 
this  disease  is  its  chronicity,  to  which  reference  has  already  been  made. 
It  is  also  essentially  a  suppurative  disease  and  it  is  notable  that  the 
suppurative  process  strips  the  soft  tis^sue  from  the  cementum,  which 
makes  the  word  pericementitis  especially  applicable.  There  is  room  for 
question  in  many  cases,  whether  or  not  the  bone  of  the  alveolar  process 
is  involved  directly  by  the  suppuration,  or  is  absorbed  secondarily  by 
purely  physiological  processes.  Therefore,  terms  which  indicate  an 
inflammation  of  the  alveolar  process  do  not  place  the  principal  tissue 
involvement  where  it  really  occurs.  Whether  this  term,  or  some  other, 
comes  to  be  finally  accepted  and  used,  it  is  imperative  that  a  name  be 
found  which  will  a])pl3'  to  this  condition  as  a  pathologic  process  different 
from  the  others  to  which  the  investing  tissues  are  subject. 


22 

The  local  causes  leading  to  the  formation  of  pus  pockets  have  been 
reviewed.  We  have  said  that  a  gingivitis  always  precedes  the  peri- 
cementitis, and  have  emphasized  the  fact  that  deposits  of  serumal  cal- 
culus and  injuries  to  the  gingivae  are  tJie  principal  local  exciting  causes. 
In  doing  this  we  do  not  overlook  the  effect  of  the  systemic  condition 


Figs.  13,  14.  Panoramic  radiographic  views  of  the  upper  and  lower 
jaws  in  a  case  of  chronic  suppurative  pericementitis  of  long  standing.  This 
patient  had  suffered  from  gout  for  five  years.  The  right  foot  was  first 
swollen  and  was  very  painful.  In  subsequent  attacks  the  ankle  was 
involved.  The  patient  stated  that  except  for  this,  he  had  never  been 
sick  a  day.  One  lower  incisor  had  become  so  loose  that  it  was  removed 
with  the  fingers.  Pressure  upon  the  gums  caused  pus  to  exude  about  the 
necks  of  many  of  the  teeth.  It  was  advised  that  all  of  the  teeth  be 
extracted. 

in  some  cases  in  which  local  causes  are  found,  and  we  also  appreciate 
the  fact  that  there  are  cases  in  which  no  local  causes  are  apparent. 
We  are,  however,  most  concerned  at  this  time  with  conditions  which  are 
recognizable  and  for  which  definite  treatment  is  indicated. 

Many  men  have  searched  for  a  specific  organism  which  might  be  proven 
to  be  the  cause  of  these  suppurations.  Up  to  the  present  time,  all  such 
attempts   have  failed.     Careful  clinical  study   of  the  progress   of   cases 


23 

contraindicates  a  specific  type  of  infection,  as  will  be  explained  later. 

The  recent  claim  of  a  number  of  writers  that  the  endameba  is  the  cause 

of  this  disease  seems  not  to  be  well   founded,   and   the   use  of   emetine 

has  proven  a  disappointment.    It  would  have  been  Just  as  logical  to  select 


Fig.  15.  Normal  peridental  membrane.  The  row  of  cementoblasts 
may  be  seen  lying  along  the  surface  of  the  cementum.  These  cells  occupy 
most  of  the  space  between  the  fibers  as  the  latter  enter  the  cementum. 
Photograph  by  Dr.  F.  B.  Noyes. 


24 


any  one  of  the  other  organisms  which  can   be  generally  found  in  these 
pockets,  and  state  that  it  alone  caused  this  disease. 

The  symptoms  and  tissue  changes  are  those  of  a  progressive  chronic 
infection.  The  appearance  of  the  gingivae  may  be  normal,  or  the  crests 
may  be  slightly  blunted  and  swollen,  with  slight  or  considerable  discolora- 
tion. The  suppuration  occurring  because  of  the  inflammation  of  the 
gingivae  sooner  or  later  involves  the  peridental  membrane  and  cuts  it 
away  from  the  cementum,  beginning  at  the  gingival  line.     When  a  detach- 


Fig.  16.  Section  through  soft  tissue  overlying  a  deep  pocket  of  many 
years'  standing  on  the  labial  side  of  the  root  of  a  lower  left  cuspid;  from 
about  the  middle  of  the  length  of  the  root.  Patient  sixty-five  years  of 
age.  Tissue  cut  away  by  Dr.  Arthur  D.  Black  on  September  29,  1913. 
Normally  the  crest  of  the  alveolar  process  should  be  present  in  a  section 
cut  in  this  position.  The  bone  has  all  disappeared,  as  have  practically  all 
of  the  fibers  of  the  peridental  membrane.  Section  prepared  by  Dr.  H.  A. 
Potts,  photographed  by  Dr.  F.  B.  Noyes. 

ment  has  been  affected,  the  general  tendency  is  for  pockets  to  slowly 
progress.  This  progress  is  greatest  toward  the  apex  of  the  root,  rather 
than  around  the  root,  so  that  it  is  not  unusual  to  find  very  deep,  narrow 
pockets.  The  cementoblasts  are  the  first  of  the  specialized  elements  to  be 
destroyed.  This  seems  to  occur  as  a  part  of  the  suppurative  detachment 
of  the  soft  tissue  from  the  root.  Subsequently,  the  principal  fibres  of 
the  peridental  membrane  gradually  disappear  from  the  overlying  tissue, 
and  later  the  bone  of  the  alveolar  process  to  which  these  fibres  were 
attached  disappears  also.     As  has  been  mentioned,  it  should  be  expected 


that  these  tissues  would  be  absorbed  following  the  detachment,  regardless 
of  their  possible  involvement  in  the  suppurative  process.  The  disap- 
pearance of  the  fibres  of  the  peridental  membrane  may  be  shown  by 
microscopical  examination  of  tissue  cut  from  these  positions;  while  the 
absorption  of  the  alveolar  process  is  clearly  shown  by  radiographs. 

The  soft  tissue  overlying  the  denuded  cementum  jjresents  a  granulating 
surface  containing  many  newly  formed,  thin-walled  blood  vessels,  which 
offer  favorable  opportunity  for  the  many  micro-organisms  within  the 
mouth  to  enter  the  circulation.  The  cementum  itself  has  necessarily 
absorbed  the  products  of  suppuration  and  putrefaction,  so  that  a  con- 
dition could  hardly  be  imagined  which  would  present  greater  difficulties 
to  a  normal  re-attachment  of  the  tissue  to  the  root.  Every  specialized 
element  of  the  peridental  membrane  has  disappeared,  and  the  tissue  which 
remains  lies  against  a  cementum  which  has  been  rendered  negatively 
chemotactic  by  absorbing  the  products  of  the  suppuration.  It  is  for  this 
reason  that  these  detachments  are  permanent  detachments. 

It  has  been  suggested  that  the  outer  surface  of  the  cementum  should 
be  cut  away,  with  the  expectation  that  an  attachment  would  occur  similar 
to  that  which  takes  place  when  teeth  are  implanted,  transplanted  or 
replanted.  We  have  not  time  to  discuss  this  point  at  length  at  this  time, 
but  attention  is  called  to  the  fact  that  the  attachment  in  such  cases  is 
an  unstable  one,  and  it  in  no  sense  a  re-attachment  of  the  peridental 
membrane.  Where  such  teeth  become  firm,  the  rule  is  that  it  is  by  absorp- 
tion of  the  root  and  building  in  of  the  surrounding  tissue,  a  process 
which,  within  a  few  years,  results  in  the  loss  of  the  tooth. 

Doubtless  many  conscientious  oi)erators  have  been  misled  into  believ- 
ing that  re-attachment  occurs;  this  has  resulted  from  their  failure  to 
observe  cases  with  sufficient  care  over  a  long  enough  period  of  time. 
It  is  the  rule  that  many  cases  look  very  much  better  following  treatment, 
and  that  there  is  close  adaptation  of  the  soft  tissue  to  the  root,  so  that 
one  may  be  deceived.  If  such  cases  are  kept  under  close  observation, 
it  will  be  found  practically  always  that  the  pockets  are  still  there,  and 
that  there  will  be  a  recurrence  of  the  pus  formation. 

Pain  is  not  a  prominent  symptom,  although  the  tissues  about  such 
teeth  will  occasionally  be  verj^  painful  when  the  suppurations  are  acute, 
or  if  the  pus  penetrates  deeply  into  the  surrounding  tissues.  Most 
patients  will  complain  that  the  teeth  are  periodically  sore  and  that  they 
are  raised  in  their  sockets.  The  greater  the  progress  of  the  case,  the  more 
frequently  will  pain  and  soreness  be  noted. 

Deposits  of  serumal  calculus  will  be  found  upon  the  denuded  cementum 
in  many  cases.  These  deposits  should  never  be  considered  a  cause,  but 
always  a  result  of  the  formation  of  the  pocket,  as  the  material  for  the 
deposit — the    calco-globulin — is    brought    to    the    pocket    by    the    serum 


26 

escaping  from  the  overlying  inflamed  tissue.  These  deposits  are  fre- 
quently nodular,  as  the  overlying  tissue  does  not  hug  closely  about  the 
root,  and  the  deposit  is  not  compressed  while  soft,  as  is  often  the  case 
with  the  deposit  on  the  enamel.  When  deposits  have  occurred  on  the 
cementum,  they  cause  additional  inflammation  of  the  overlying  tissue 
and  in  this  way  contribute  to  the  further  progress  of  the  pocket 

The  cervical  lymphatic  glands  are  occasionally  enlarged  in  advanced 
cases.  There  is  also,  as  a  rule,  an  excitation  of  the  salivary  glands,  re- 
quiring the  patient  to  swallow  frequently  and  possibly  to  drool  at  night. 

Pus  pockets  may  be  divided  into  two  groups,  according  to  their 
location.  In  many  cases  the  pockets  will  all  be  on  proximal  surfaces, 
with  little  or  no  involvement  of  buccal,  labial  or  lingual  surfaces.  In 
others,  all  the  pockets  will  be  on  buccal,  labial  or  lingaal  surfaces.  In 
the  later  stages,  all  surfaces  will  be  involved.  It  is  not  uncommon  to 
find  a  single  pocket  on  the  labial  or  buccal  surface,  or  possibly  two  or 
three.  The  lingual  surfaces  of  the  upper  incisors  are  frequently  involved 
as  a  group. 

The  tendency  is  for  teeth  having  pus  pockets  on  one  side  to  move  in 
the  direction  away  from  the  pocket.  This  is  partly  due  to  the  inflam- 
mation, but  principally  to  the  fact  that  the  balance  of  pull  of  the  various 
fibres  of  the  peridental  membrane  has  been  disturbed  and  the  fibres  on 
the  sound  side  pull  the  tooth  in  that  direction.  When  the  pockets  are 
on  the  lingual  side  of  the  upper  incisors,  these  teeth  generally  move 
labially  and,  with  the  pull  of  the  trans-septal  fibres,  soon  draw  the  cuspids 
away  from  the  first  bicuspids  and  open  the  contacts.  The  contacts  between 
the  incisors  and  cuspids  are  also  opened  by  the  forward  movement,  and 
the  septal  tissues  soon  become  inflamed  from  food  impactions.  When  the 
labial  movement  of  the  incisors  has  once  fairly  begun,  it  is  seldom 
checked  and  after  a  time  the  teeth  are  lost.  Very  often  the  forward 
movement  of  the  cuspids  results  in  the  eventual  loss  of  the  bicuspids  and 
molars  also. 

In  cases  in  which  the  original  pocket  is  alongside  a  proximal  surface 
in  the  bicuspid  or  molar  region,  the  neighboring  teeth  are  likely  to  become 
similarly  involved  on  their  proximal  surfaces,  the  buccal  and  lingual 
tissues  remaining  intact.  When  such  a  pocket  occurs,  the  inflammation 
within  the  septal  space,  together  with  the  pull  of  the  fibres  on  the 
opposite  sides  of  both  teeth,  tend  to  open  the  contact  between  the  teeth. 
When  this  occurs,  there  is  usually  some  pressure  on  next  neighboring 
contacts,  with  slight  movement  of  the  adjacent  teeth.  With  the  subsid- 
ence of  the  inflammation,  the  teeth  return  to  their  normal  positions.  This 
is  repeated  again  and  again,  until  after  a  time  the  frequent  movement 
results  in  the  weakening  of  neighboring  contacts  and  stringy  foods  are 
forced  through,  causing  inflammation  of  the  septal  tissues.    This  continues 


27 

until  pus  pockets  are  formed  on  the  proximal  surfaces  of  these  teeth. 
In  this  slow  way  these  cases  progress.  The  movement  of  the  teeth 
of  one  arch  will  often  disturb  those  of  the  opposite  arch  and  similar 
inflammations  will  follow.  Thus  all  the  teeth  may  be  lost  as  a  result 
of  a  single  proximal  pus  pocket. 

Occasionally  the  pus  formed  iu  deep  pockets  is  not  discharged  along- 
side the  root,  but  involves  the  adjacent  soft  tissues  and  forms  an  acute 
abscess  at  the  side  of  the  root.  This  is  a  lateral  abscess.  It  may  be 
mistaken  for  a  true  alveolar  abscess. 


Treatment 

The  key  to  the  treatment  of  chronic  suppurative  pericementitis  is  in 
the  statement  that  suppurative  detachments  of  the  peridental  membrane 
are  permanent  detachments.  With  this  in  mind,  we  may  divide  the 
treatment  under  three  headings:   preventive,  palliative  and  radical. 

Preventive  treatment  consists  of  the  carrying  out  in  pactice  of  every 
measure  which  will  prevent  or  cure  gingivitis  and  thus  protect  the 
peridental  membrane.  The  methods  of  doing  this  have  already  been 
discussed.  This  treatment  must  be  by  the  general  practitioner  of  dentistry 
and  not  by  a  specialist,  for  it  must  come  to  be  a  part  of  every  dental 
operation  to  conserve  the  health  of  the  investing  tissues.  This  must 
be  done  by  careful  systematic  examinations,  properly  recorded;  by  the 
maintenance  of  good  contacts  to  promote  thorough  mastication,  and  careful 
training  of  patients  in  mouth  hygiene.  This  should  come  to  be  a  con- 
siderable part  of  the  practice  of  each  dentist — and  it  should  be  the 
service  by  which  a  substantial  portion  of  his  income  will  be  earned. 
Practitioners  who  follow  such  a  plan  will  have  very  few  patients  in 
whose  mouths  pus  pockets  will  occur. 

Palliative  treatment  should  be  applied  in  those  cases  in  which  pus 
jiockets  have  formed,  but  are  not  bad  enough  to  require  the  extraction 
of  the  teeth  involved.  It  is  not  possible  to  give  a  definite  rule  by  which 
the  line  may  be  sharply  drawn  between  those  conditions  which  demand 
extraction  and  those  which  contra-indicate  this  operation.  More  will  be 
said  on  this  point  later. 

If  palliative  treatment  is  undertaken,  the  first  procedure  should  usu- 
ally be  the  removal  of  deposits  from  the  roots,  if  deposits  are  present. 
It  makes  little  dift'erence  what  instruments  are  used,  if  the  operator  is 
able  to  remove  the  deposits.  A  large  number  of  scalers  is  not  necessary, 
for  it  is  believed  that  other  means  should  be  employed  instead  of  scaling 
operations  if  there  are  deposits  in  positions  of  very  difficult  access.  It  is 
certainly  of  the  greatest  importance  that  each  operator  should  develop 
the  best  possible  finger   skill. 


The  instruments  should  be  sharp  and  the  effort  should  be  made  to 
remove  all  the  deposit  and  leave  the  root  smooth.  In  doin^  this,  as 
much  as  possible  of  the  cementum  should  be  left  on  the  root.  The  removal 
of  the  cementum  causes  many  teeth  to  become  hypersensitive,  so  that 
thermal  changes  or  even  the  mastication  of  food  is  painful.  It  should 
be  borne  in  mind  that  there  is  no  physiological  provision  for  transmission 
of  sensation  through  cementum.  Therefore  there  should  be  no  sensation 
transmitted  through  the  pulp  in  scaling  operations,  so  long  as  the  cemen- 
tum is  intact.  Sometimes  acid  formed  by  organisms  growing  within  a 
pocket  will  soften  the  cementum,  so  that  it  is  easily  removed,  or  it  may 
be  removed  by  repeated  scaling  operations.  One  case  has  been  presented 
in  which  the  pulp,  within  the  root-canal,  was  actually  exposed  by  the  too 
vigorous  use  of  scalers. 

If  pain  is  caused  in  the  overlying  tissues  by  scaling  operations,  novo- 
cain may  be  injected.  However,  in  such  cases  I  have  generally  preferred 
to  remove  the  bulk  of  the  deposits,  which  can  usually  be  done  without 
much  pain,  at  the  first  sitting,  and  then,  by  thoroughly  irrigating  the 
pockets  with  salt  solution  on  two  or  three  successive  days,  bring  about 
sufficient  reduction  of  the  inflammation  that  the  more  thorough  scaling 
can  be  done  without  causing  pain. 

Following  the  scaling,  the  case  should  be  observed  by  the  dentist  until 
the  inflammation  has  subsided,  irrigating  all  pockets  thoroughly  at  each 
visit.  The  patient  should  then  be  carefully  instructed  in  the  use  of  the 
rubber  bulb  syringe  and  should  be  impressed  with  the  necessity  of  irriga- 
tion twice  daily  with  normal  salt  solution.  By  this  plan  the  pockets 
will  be  kept  clean  and  free  from  accumulations  or  micro-organic  growths, 
and  the  recurrence  of  deposits  will  be  in  large  measure  prevented.  After 
the  roots  are  once  thoroughly  cleaned,  the  irrigation  by  the  patient  be- 
comes the  most  important  factor  in  the  prognosis  of  most  cases,  and  its 
importance  cannot  be  too  strongly  impressed.  There  should  of  course  be 
an  arrangement  for  subsequent  examinations,  and  further  treatment  when 
necessary. 

In  a  limited  number  of  cases,  the  cleansing  operations,  and  incidentally 
the  scaling,  may  be  simplified  by  cutting  away  the  overlying  soft  tissue 
and  thus  materially  reducing  the  depth  of  the  pocket.  This  treatment 
is  most  frequently  indicated  for  pockets  on  labial  or  buccal  surfaces.  , 

Time  will  not  permit  a  discussion  of  the  reasons  for  the  abandonment 
of  antiseptics  in  the  treatment  of  these  pockets.  It  need  only  be  said 
that  antiseptics  were  originally  used  here  for  the  same  reason  that  they 
were  used  in  other  infected  cavities  by  surgeons,  to  inhibit  the  growth 
of  the  organisms.  Today  we  should  abandon  their  use  for  the  same  reason 
that  surgeons  have  generally  done  so,  because  it  has  been  found  that  they 
do  more  harm  than  good;  that  an  antiseptic  which  will  be  effective  against 


29 

micro-organisms  will  also  so  inhibit  the  activities  of  the  tissue  that  noth- 
ing is  gained.  By  the  use  of  salt  solution,  most  of  the  organisms  are 
washed  away  and  the  tissues  are  left  in  the  best  condition  to  destroy  the 
remainder. 


Fig.  17.  Plaster  model  of  ease  in  wliich  the  tissue  overlying  a  pocket 
on  the  mesio-buccal  root  of  an  upper  first  molar  was  cut  away  to  reduce 
the  depth  of  the  pocket  and  facilitate  the  cleaning. 


Fig.  18.  A  case  in  which  the  distal  root  of  a  lower  first  molar  was 
amputated.  The  distal  half  of  the  crown  of  the  tooth  was  also  cut  away, 
and  a  gold  crown  was  made  to  restore  the  full  occlusal  surface. 

This  plan  of  treatment  is  quite  simple,  but  is  very  effective  if  the 
co-operation  of  the  patient  can  be  secured.  So  long  as  the  pockets  are 
kept  clean,  they  are  practically  well,  and  both  the  teeth  and  the  health 
of  the  patient  are  conserved. 

Eadical  treatment  for  these  cases  consists  of  extraction  or  root  ampu- 
tation. As  a  general  statement,  it  may  be  said  that  we  have  gone  too 
far  in  our  effort  to  save  these  teeth.      When  so  much  of  the  investing 


30 

tissue  has  been  destroyed  that  the  tooth  is  very  loose,  it  should  be  ex- 
tracted. If  a  tooth  has  deep  pockets  and  is  periodically  sore  enough 
to  interfere  with  proper  mastication,  it  should  be  extracted.  If  the  for- 
mation of  pus  can  not  be  controlled,  the  tooth  should  be  extracted.  In 
most  cases,  if  the  disease  has  progressed  to  denude  the  bifurcation  of 
multi-rooted  teeth,  they  should  be  extracted.  Eoot  amputation  may  be 
substituted  for  extraction  in  cases  in  which  a  single  root  of  a  multi- 
rooted tooth  is  diseased,  while  the  other  root  or  roots  are  not.  The 
lingual  root  of  the  upper  first  molar  offers  the  best  opportunity  for  suc- 
cessful amputation.  It  often  requires  a  very  careful  study  of  eases  to 
come  to  a  proper  decision  regarding  extraction.  We  certainly  should 
not  be  guided  by  the  usefulness  of  the  tooth  in  mastication  alone,  as  many 
teeth  which  are  serviceable  are  a  decided  menace  to  health. 


FIFTH  LECTURE 

MANAGEMENT    OF    CASES 

SYSTEMIC  EFFECTS  OF  MOUTH  INFECTIONS 

In  the  previous  lectures,  we  have  discussed  the  several  diseases  to 
which  the  gingivae  and  peridental  membrane  are  subject,  considering  the 
pathology  and  treatment  of  each  separately.  In  many  mouths  several 
or  all  these  conditions  may  be  present  at  the  same  time.  An  accurate 
and  complete  diagnosis  is  therefore  often  difficult,  as  is  the  determina- 
tion of  the  best  plan  of  treatment.  For  this  reason  a  definite  system  of 
making  and  recording  examinations  becomes  a  matter  of  first  importance. 
In  the  clinics  accompanying  these  lectures  I  have  demonstrated  a  simple 
plan  by  which  each  area  of  inflammation  may  be  recorded  by  a  number, 
which  will  indicate  the  condition  of  the  tissue,  the  position,  and  the  cause. 
It  requires  a  little  experience  to  become  familiar  with  any  such  plan,  yet 
the  advantage  gained  by  having  made  and  recorded  such  complete  surveys 
of  the  mouth  will  fully  compensate  for  the  effort.  The  habit  of  doing 
this  will  sharpen  one's  observation  and  put  one  in  position  to  lay  out 
a  comprehensive  plan  of  treatment.  Every  area  of  gingivitis,  the  loca- 
tions of  deposits  of  both  salivary  and  serumal  calculus,  the  condition 
of  contacts,  the  location  and  depth  of  pockets,  teeth  which  are  missing, 
those  which  are  loose,  and  many  other  items  are  necessary  to  a  complete 
record.  In  cases  in  which  there  are  pockets,  radiographs  should  be  made 
for  the  additional  information  which  they  will  give  and  to  verify  the 
instrumental  examination.  In  some  eases  inquiry  should  be  made  into 
the  general  physical  condition  of  the  patient. 


31 


With  all  the  facts  obtainable,  one  is  ready  to  lay  plans  for  treatment. 
It  should  first  be  determined  what  teeth  unquestionably  require  extraction, 
then  those  which  should  unquestionably  receive  palliative  or  preventive 
treatment.  There  may  be  several  regarding  which  there  is  some  question 
and  oftentimes  it  will  be  wise  to  reserve  one's  judgment  regarding  these 
for  a  little  time,  possibly  for  several  months,  until  the  attitude  of  the 
patient  towards  the  technic  of  mouth  hygiene  has  been  observed.  It 
will  be  possible  to  retain,  without  menace  to  the  health,  teeth  with 
tolerably  deep  pockets  in  one  mouth,  if  the  use  of  the  syringe  is  faith- 
fully carried  out,  while  in  another  even  quite  shallow  pockets  will  con- 
stitute a  serious  menace  if  they  do  not  receive  proper  irrigation. 

The  problem  of  appearance,  and  that  of  replacing  lost  teeth  to  pro- 
vide a  means  of  proper  mastication,  must  have  consideration  at  the 
same  time.  Often  it  will  be  best  to  remove  some  of  the  ''doubtful" 
teeth  in  order  to  give  better  abutments  for  a  bridge,  or  if  a  denture  must 
be  made,  there  may  be  an  advantage  in  extracting  several  such  teeth. 

The  general  attitude  of  our  people  in  favor  of  saving  every  tooth 
as  long  as  possible  presents  one  other  difficulty  in  the  management  of 
these  cases.  When  it  has  been  determined  that  certain  teeth  should  be 
extracted,  careful  dipomacy  must  often  be  used  in  our  advice  to  the 
patient.  I  have,  on  several  occasions,  given  patients  what  I  am  sure 
was  sound  advice  to  the  effect  that  they  should  have  many  or  all  of 
their  teeth  extracted,  with  the  result  that  I  did  not  see  them  again. 
We  should  always  bear  in  mind  the  fact  that  the  loss  of  the  teeth  is  a 
serious  thing  in  the  life  of  most  persons,  and  some  time  is  often  required 
to  bring  them  to  a  proper  realization  of  the  situation  which  confronts 
them.  It  is  often  best,  therefore,  first  to  suggest  and  later  to  state 
definitely  what  seems  best,  with  our  reasons. 

The  studies  by  medical  men  in  recent  years  have  brought  to  us  another 
proposition  for  very  serious  consideration;  viz.,  the  relation  of  the  local 
foci  of  infection  to  many  serious  systemic  diseases.  This  relationship  has 
been  recognized  by  a  few  men  for  many  years,  but  was  not  prominently 
before  either  the  medical  or  the  dental  professions  until  Hunter,  of 
London,  wrote  his  famous  article  in  1911. 

As  early  as  1891  our  own  Dr.  W.  D.  Miller  wrote  as  follows:  "During 
the  last  few  years  the  conviction  has  grown  continually  stronger  among 
physicians,  as  well  as  dentists,  that  the  human  mouth,  as  a  gathering 
place  and  incubator  of  pathogenic  germs,  performs  a  significant  role  in 
the  production  of  varied  disorders  of  the  body,  and  that  if  many  diseases, 
whose  origin  is  enveloped  in  mystery,  could  be  traced  to  their  source, 
they  would  be  found  to  have  originated  in  the  oral  cavity." 

Dr.  Hunter  wrote  his  first  paper  in  1900,  but  it  was  not  until  eleven 
years   later,   after   he   had   seen    hundreds   of   patients   improve   or   fully 


32 

recover  from  those  diseases  which  are  now  recognized  as  occuring  secon- 
dary to  local  foci,  as  a  result  of  practically  no  other  treatment  than  the 
clearing  of  the  mouths  from  infection,  that  he  wrote  a  scathing  article 
which  brought  both  professions  to  their  feet.  Among  other  things.  Dr. 
Hunter  said  in  this  paper:  ''Sepsis  in  medicine  therefore  ranks,  in  my 
experience,  as  the  most  prevalent  and  potent  infective  disease  in  the 
body.  It  therefore  deserves  the  particular  attention  of  the  whole  profes- 
sion as  much  as  it  has  hitherto  received  their  particular  neglect.  It 
requires  this  attention  at  the  hands  of  every  branch  of  the  profession." 
Dr.  Hunter's  investigations  seem  to  have  been  confined  principally  to 
clinical  observations  and  case  histories,  yet  they  are  of  great  value 
because  of  the  large  number  and  variety  of  cases  reported. 

The  studies  of  Dr.  Frank  Billings  and  the  group  of  men  associated 
with  him  in  Chicago  have  been  along  more  scientific  lines,  and  have 
given  unquestionable  proof  of  Dr.  Hunter's  observations.  Dr.  Billings 
says:  "Systemic  disease  due  to  a  focus  of  infection  anywhere  is  pro- 
bably always  hematogenous.  The  study  of  infected  tissues  of  experi- 
mentally inoculated  animals,  and  the  infected  muscles,  joint  tissues, 
lymph  nodes  proximal  to  infected  joints,  nodes  on  tendons,  etc.,  of 
patients,  yield  specific  bacteria,  and  histologically  there  is  found  em- 
bolism of  the  small  and  terminal  blood  vessels.  Local  hemorrhage  and 
endoarterial  proliferation  result  in  interstitial  overgrowth,  cartilagenous, 
osseous,  vegetative  and  other  morbid  anatomical  changes,  dependent  on 
the  character  of  the  tissue  infected."  This  one  quotation  will  suffice  to 
impress  the  fact  that  Dr.  Billings'  investigations  have  been  exceptionally 
thorough. 

Dr.  E.  C.  Eosenow  has  done  most  of  the  bacteriological  work  for  Dr. 
Billings'  cases  and  his  investigations  have  demonstrated  that  many 
changes  occur  in  the  morphology  of  organisms  in  accordance  with  their 
environment,  also  that  they  develop  as  yet  unexplained  affinities  for 
certain  tissues.  This  was  proven  by  the  use  of  fresh  cultures  from  four 
groups  of  cases;  appendicitis,  ulcers  of  the  stomach,  cholecystitis,  and 
arthritis.  The  cultures  were  injected  into  veins  of  dogs  and  rabbits,  and 
in  each  group  a  very  large  majority  of  the  animals  developed  inflammations 
of  the  very  same  tissues  as  those  from  which  the  cultures  were  made, 
while  there  were  inflammations  of  comparatively  few  of  the  other  tissues. 

In  the  light  of  our  present  knowledge,  we  are  justified  in  making  the 
following  summary  of  the  relation  of  mouth  foci  to  general  systemic 
conditions: 

1.  The  mouth  contains  a  large  variety  of  micro-organisms,  which  may 
be  divided  into  two  groups;  those  which  are  normal  or  constantly  present, 
and  those  occasionally  or  frequently  found. 


33     '..    ■    ■   .     '• 

2.  Conditions  in  the  mouth  are  stlahtnat*  sHght'iiiflaniraatioils  of  the 
gingivae  are  of  frequent  occurrence,  being  present  in  about  ninety-five 
per  cent  of  mouths  of  adults. 

3.  These  slight  inflammations,  if  untreated,  may  gradually  progress 
to  chronic  suppurations.  The  suppurations  are  caused  by  organisms 
normal  to  the  mouth. 

4.  All  organisms  in  the  mouth,  whether  normal  or  accidental,  have 
access  to  the  blood  stream  through  the  soft  granulations. 

5.  The  normal  resistence  tends  to  prevent  systemic  effects  and  is 
apparently  successful  in  the  large  majority  of  cases. 

6.  The  transmission  of  infection  from  the  primary  focus  is  princi- 
pally hematogenous. 


Fig.  19.  Lower  jaw  of  a  Flat-Head  Indian  from  Columbia  River, 
Oregon,  showing  destruction  of  bone  by  a  chronic  alveolar  abscess  about 
the  distal  root  of  the  first  molar.  The  bone  about  the  first  molar  of  the 
opposite  side  is  in  practically  the  same  condition.  This  is  typical  of  the 
injury  which  occurs.  • 


7.  The  primary  focus  is  characterized  by  suppuration,  while  the  secon- 
dary lesion  is  non-suppurative.  Therefore  the  secondary  lesion  is  not 
caused  by  the  principal  organism  of  the  primary  focus,  but  by  other 
organisms  which  enter  the  primary  focus  with  or  after  the  pus  producer, 
and  thus  gain  access  to  the  circulation;  or  else  the  morphology  of  the 
pyogenic  organism  is  changed  if  it  produces  the  secondary  lesion. 

8.  The  organisms  entering  the  circulation  through  such  foci  appear 
to  have  an  as  yet  unexplained  tendency  to  locate  in  particular  tissues. 

9.  The  secondary  effects  include  a  very  wide  range  of  conditions. 
Chronic  arthritis,  endocarditis,  nephritis,  cholecystitis,  ulcers  of  the  stom- 
ach, and  appendicitis  are  the  most  frequent  definite  lesions.  General 
impairment  of  health  and  vigor,  with  or  without  recognizable  lesions,  is 
common. 


34 

10.  T'he  sec6Adar;^  effects'  ia're  usually  insidious  in  their  onset  and  pro- 
gress and,  when  cases  present  to  physicians  for  treatment,  are  often 
difficult  of  management. 

11.  It  is  imperative  that  the  primary  foci  be  eliminated,  regardless 
of  the  apparent  systemic  effect  or  lack  of  systemic  effect. 

12.  For  the  reason  that  the  mouth  contains  the  primary  foci  in  the 
large  majority  of  cases,  a  great  opportunity  is  open  to  the  dental  pro- 
fession to  prevent  grave  systemic  disease. 

The  chronic  foci  of  the  mouth  may  be  divided  into  three  groups: 
(1)  Deposits  of  salivary  calculus.  There  may  be  included  in  this  group 
all  fillings,  crowns  or  bridges  which  impinge  on  the  soft  tissues  and  keep 
them  in  a  constant  state  of  irritation,  in  somewhat  the  same  manner  as 
does  a  deposit  of  calculus.  In  all  cases  of  this  group  the  rule  is  that 
the  systemic  danger  is  removed  with  the  relief  of  the  pressure  contact 
on  the  soft  tissue,  (2)  Pus  pockets  alongside  roots  resulting  from  a 
suppurative  gingivitis.  (3)  Chronic  alveolar  abscesses.  Each  of  the 
latter  two  causes  the  detachment  of  the  peridental  membrane  from  the 
cementum,  and  the  denuded,  pus-soaked  cementum  is  the  chief  factor  in 
maintaining  the   chronicity   of  these. 

Today  a  thorough  search  for  mouth  infection  is  usually  undertaken 
only  in  cases  in  which  secondary  symptoms  are  manifest,  and  generally 
after  the  physician  has  been  consulted.  We  know  that  many  such  cases 
will  not  be  benefited  by  the  removal  of  the  cause  at  this  time,  because 
the  secondar}^  effect  is  already  too  well  established.  May  I  suggest  that 
the  highest>(i«47— "ofthe  dental  profession  today  is  to  search  for  and 
eliminalFethese  foci  be??^TTrsecondary  lesions  are  manifest!  If  a^inority 
of  tjiese^TCcT'are  known  to  havecatTsecT  serious  secondary  effects,  the 
majority  should  be  eliminated  while  there  is  the  opportunity  to  protect 
the  health.  This  is  the  opportunity  which  is  before  the  dental  profession 
today.  Such  men  as  Billings,  Osier,  Mayo,  Hunter,  and  others  have  ex- 
pressed it  as  their  belief  that  the  majority  of  the  secondary  lesions  are 
from  primary  foci  in  the  mouth,  which  means  that  the  dental  profession 
can  prevent  these  diseases  if  they  appreciate  the  situation  and  seize  the 
opportunity. 

In  giving  this  course  of  lectures,  it  has  been  my  endeavor  to  stimulate 
your  interest  in  this  subject.  What  I  have  presented  is  necessarily  super- 
ficial and  must  be  supplemented  by  an  extended  study  of  what  has  been 
written,  together  with  careful  observation  and  application  in  daily  prac- 
tice. If  I  have  set  some  of  you  to  thinking,  so  that  as  time  passes  your 
appreciation  of  these  conditions  will  be  better,  I  shall  have  accomplished 
my  purpose. 


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